1 00:00:02,480 --> 00:00:05,299 Today's clinical providers and healthcare systems 2 00:00:05,599 --> 00:00:08,400 need a strategic partner that is focused on 3 00:00:08,400 --> 00:00:10,339 the evolution of healthcare delivery. 4 00:00:10,880 --> 00:00:14,000 At Surgery Partners, we are redefining the healthcare 5 00:00:14,000 --> 00:00:15,074 industry community. 6 00:00:45,454 --> 00:00:47,554 At surgerypartners.com. 7 00:00:50,015 --> 00:00:52,255 This is Carly Beam with Becker Spine and 8 00:00:52,255 --> 00:00:53,475 Orthopedics podcast. 9 00:00:53,854 --> 00:00:55,854 I'm thrilled to be joined today by doctor 10 00:00:55,854 --> 00:00:57,715 Todd Landman of Cedars Sinai. 11 00:00:58,094 --> 00:01:00,015 Doctor Landman, thank you so much for being 12 00:01:00,015 --> 00:01:00,755 here today. 13 00:01:01,409 --> 00:01:03,809 Thank you, Carly. It's a pleasure. I'm happy 14 00:01:03,809 --> 00:01:05,650 to meet with you and speak to you 15 00:01:05,650 --> 00:01:08,310 about all the latest and greatest in 16 00:01:08,689 --> 00:01:09,590 spine technologies, 17 00:01:09,890 --> 00:01:12,469 especially in motion preservation surgery. 18 00:01:13,009 --> 00:01:15,189 Absolutely. And before we get into our conversation 19 00:01:15,329 --> 00:01:17,844 about the latest and greatest, can you share 20 00:01:17,844 --> 00:01:19,545 a bit more about your background? 21 00:01:20,484 --> 00:01:21,465 Yes. I, 22 00:01:22,484 --> 00:01:24,724 well, I trained in medicals how far do 23 00:01:24,724 --> 00:01:25,765 you wanna go back? I mean, I can 24 00:01:25,765 --> 00:01:27,604 go back to my childhood and everything. But 25 00:01:27,604 --> 00:01:30,439 we'll probably just go medical school at Northwestern 26 00:01:30,739 --> 00:01:31,399 in Chicago 27 00:01:31,939 --> 00:01:34,759 and then UCLA training for, neurosurgery. 28 00:01:35,619 --> 00:01:37,159 So even though it's an orthopedic 29 00:01:37,700 --> 00:01:38,200 podcast, 30 00:01:38,500 --> 00:01:39,000 technically, 31 00:01:39,859 --> 00:01:42,194 but neurosurgery and orthopedics both, 32 00:01:42,834 --> 00:01:46,034 do spine surgery. So neurosurgery is seven years 33 00:01:46,034 --> 00:01:46,775 at UCLA. 34 00:01:47,155 --> 00:01:50,354 And then after that, I've been, at Cedars 35 00:01:50,354 --> 00:01:53,575 Sinai Medical Center, an associate professor at UCLA. 36 00:01:54,435 --> 00:01:56,750 So I still do teach there. However, 37 00:01:57,049 --> 00:01:59,310 I am part of the Institute of, 38 00:02:00,409 --> 00:02:02,409 Spine Institute of Excellence and the Institute of 39 00:02:02,409 --> 00:02:03,390 Spinal Disorders 40 00:02:04,010 --> 00:02:06,090 at Cedars Sinai Medical Center and have been 41 00:02:06,090 --> 00:02:08,030 for over thirty years. 42 00:02:08,490 --> 00:02:10,185 So I've been working with 43 00:02:10,985 --> 00:02:13,224 the group there and the teams there and, 44 00:02:13,544 --> 00:02:16,664 working on, artificial disc replacement primarily as my 45 00:02:16,664 --> 00:02:17,965 focus in motion preservation 46 00:02:18,584 --> 00:02:19,485 of the spine. 47 00:02:20,185 --> 00:02:21,944 Thank you. And, you know, when it comes 48 00:02:21,944 --> 00:02:25,039 to total disc replacement, what's exciting you in 49 00:02:25,039 --> 00:02:26,580 that sphere right now? 50 00:02:27,759 --> 00:02:28,659 Yes. Well, 51 00:02:29,439 --> 00:02:30,259 several things. 52 00:02:30,800 --> 00:02:31,120 Every 53 00:02:31,680 --> 00:02:34,419 especially in the cervical spine, we're seeing more 54 00:02:35,919 --> 00:02:38,979 devices being approved and being investigated, 55 00:02:40,135 --> 00:02:41,514 and there's new technologies. 56 00:02:42,215 --> 00:02:44,615 And so there's some really interesting things that 57 00:02:44,615 --> 00:02:46,075 are happening that are exciting. 58 00:02:46,534 --> 00:02:48,075 One is that 59 00:02:48,455 --> 00:02:50,375 there are some new devices that will be 60 00:02:50,375 --> 00:02:51,115 coming out 61 00:02:51,495 --> 00:02:53,115 that are able to preserve 62 00:02:53,829 --> 00:02:54,969 sort of angulation 63 00:02:55,269 --> 00:02:58,090 or or alignments of the spine better. 64 00:02:58,389 --> 00:02:59,530 So there's some newer 65 00:03:00,310 --> 00:03:00,810 devices, 66 00:03:01,189 --> 00:03:01,689 particularly 67 00:03:01,989 --> 00:03:02,489 one, 68 00:03:03,349 --> 00:03:03,669 that, 69 00:03:04,150 --> 00:03:06,870 should be FDA approved maybe late this year, 70 00:03:06,870 --> 00:03:08,090 early next year, 71 00:03:08,754 --> 00:03:09,495 that provides 72 00:03:10,115 --> 00:03:11,715 curve of the neck so that your neck 73 00:03:11,715 --> 00:03:12,775 should curve backwards. 74 00:03:13,235 --> 00:03:16,215 And this this artificial disc still allows mobility, 75 00:03:16,594 --> 00:03:18,534 but helps maintain the alignment 76 00:03:18,995 --> 00:03:19,495 properly. 77 00:03:19,875 --> 00:03:21,634 So that's more exciting because a lot of 78 00:03:21,634 --> 00:03:22,935 the disc that we have now 79 00:03:23,750 --> 00:03:26,310 really let your neck set itself where it 80 00:03:26,310 --> 00:03:27,370 wants to go. 81 00:03:27,669 --> 00:03:29,689 And because of the latest technologies, 82 00:03:30,789 --> 00:03:31,930 phones, laptops, 83 00:03:32,389 --> 00:03:34,889 so forth, we tend to flex forward mostly. 84 00:03:35,189 --> 00:03:36,405 And so you can have 85 00:03:36,965 --> 00:03:38,264 kyphosis or that 86 00:03:38,645 --> 00:03:41,365 flex forward or what I call a chicken 87 00:03:41,365 --> 00:03:42,185 neck looking 88 00:03:42,884 --> 00:03:45,365 deformity where the, you know, people's head falls 89 00:03:45,365 --> 00:03:48,324 forward. And most artificial discs will allow you 90 00:03:48,324 --> 00:03:50,199 to roll forward, so it takes a lot 91 00:03:50,199 --> 00:03:53,000 of rehabilitation and strengthening of the muscles to 92 00:03:53,000 --> 00:03:53,500 really 93 00:03:54,599 --> 00:03:56,599 keep the head in alignment. So there's new 94 00:03:56,599 --> 00:03:58,680 technology coming out that may help that and 95 00:03:58,680 --> 00:04:01,180 make that process much easier for the patients. 96 00:04:01,800 --> 00:04:03,419 The other thing that's, 97 00:04:03,879 --> 00:04:04,379 happening 98 00:04:05,775 --> 00:04:06,254 is, 99 00:04:06,974 --> 00:04:07,474 viscoelastic 100 00:04:09,135 --> 00:04:11,395 discs, which are soft core 101 00:04:11,854 --> 00:04:12,354 discs, 102 00:04:13,375 --> 00:04:14,915 have gained some traction 103 00:04:16,014 --> 00:04:19,789 outside The US. There's one that's FDA approved 104 00:04:19,849 --> 00:04:20,750 in The US 105 00:04:21,449 --> 00:04:22,909 for the cervical spine. 106 00:04:23,529 --> 00:04:25,610 However, they just pulled it off the market. 107 00:04:25,610 --> 00:04:27,310 And what we've seen is 108 00:04:27,769 --> 00:04:29,529 and what I think people need to really 109 00:04:29,529 --> 00:04:30,029 remember 110 00:04:30,704 --> 00:04:33,824 is any implant that moves, whether it's a 111 00:04:33,824 --> 00:04:35,845 total hip or total knee or shoulder 112 00:04:36,225 --> 00:04:36,725 replacement, 113 00:04:37,584 --> 00:04:39,504 artificial disc in the neck or the low 114 00:04:39,504 --> 00:04:42,144 back, any implant that has motion will have 115 00:04:42,144 --> 00:04:42,644 wear. 116 00:04:43,479 --> 00:04:44,220 And so 117 00:04:45,399 --> 00:04:47,579 how fast does that implant wear? 118 00:04:48,360 --> 00:04:51,000 So we do know that the more common 119 00:04:51,000 --> 00:04:52,379 implants that have 120 00:04:52,919 --> 00:04:53,419 hard, 121 00:04:54,279 --> 00:04:57,305 ultrahigh molecular weight polyethylene cores, cores, for example, 122 00:04:57,685 --> 00:04:58,504 with titanium 123 00:04:59,764 --> 00:05:00,665 tend to last, 124 00:05:01,605 --> 00:05:04,725 like, forever. Seventy years, probably. They've been cycled 125 00:05:04,725 --> 00:05:05,225 on 126 00:05:05,925 --> 00:05:08,105 in what what we call life year repetitive 127 00:05:08,324 --> 00:05:11,145 motions on these machines that replicate life years 128 00:05:11,659 --> 00:05:13,579 for over seventy years, and they're still very 129 00:05:13,579 --> 00:05:14,079 functional. 130 00:05:14,779 --> 00:05:15,259 And, 131 00:05:15,899 --> 00:05:16,800 but the viscoelastic 132 00:05:17,339 --> 00:05:19,819 course, sort of the soft core disc. Right? 133 00:05:19,819 --> 00:05:21,740 Because our our human disc will be more 134 00:05:21,740 --> 00:05:22,240 compressible. 135 00:05:22,699 --> 00:05:25,419 It allows motion up and down. Well, our 136 00:05:25,579 --> 00:05:27,464 the hardcore discs don't do that. 137 00:05:28,105 --> 00:05:30,185 When you look at the data carefully, though, 138 00:05:30,185 --> 00:05:33,004 there's no real difference in the outcomes between 139 00:05:33,384 --> 00:05:36,024 the sets of patients. Those the soft core 140 00:05:36,024 --> 00:05:38,985 just sound intuitively better, but they do not 141 00:05:38,985 --> 00:05:40,604 show any better outcome. 142 00:05:40,979 --> 00:05:43,079 What they are happening to show, however, 143 00:05:43,860 --> 00:05:46,120 is the core is wearing out early, 144 00:05:46,660 --> 00:05:48,199 which means then you're back 145 00:05:48,500 --> 00:05:51,959 to revise it. And nobody wants spine surgery 146 00:05:52,019 --> 00:05:55,139 again if they can avoid it. And so 147 00:05:55,139 --> 00:05:57,495 the the soft core discs that are not 148 00:05:57,495 --> 00:05:59,654 available in The US are also having some 149 00:05:59,654 --> 00:06:01,894 issues, and I've removed a lot that's my 150 00:06:01,894 --> 00:06:04,314 patients who have gone to Europe particularly 151 00:06:05,175 --> 00:06:06,314 for those discs. 152 00:06:07,095 --> 00:06:08,074 I've taken out 153 00:06:08,535 --> 00:06:09,595 many here. 154 00:06:10,110 --> 00:06:12,189 And the one that was approved here, there's 155 00:06:12,189 --> 00:06:14,129 some issue with the core, 156 00:06:14,750 --> 00:06:17,229 as well, and the company's taken that off 157 00:06:17,229 --> 00:06:18,689 the market for now. 158 00:06:19,069 --> 00:06:22,110 So that's sort of coming up. The last 159 00:06:22,110 --> 00:06:23,410 thing to mention really 160 00:06:24,110 --> 00:06:24,610 is 161 00:06:25,245 --> 00:06:27,485 I'm I I I I'm trying to help 162 00:06:27,485 --> 00:06:28,704 patients connect, 163 00:06:29,884 --> 00:06:33,024 with the most experienced and qualified disc replacement 164 00:06:33,084 --> 00:06:34,625 surgeries in The United States 165 00:06:35,004 --> 00:06:35,644 because they're 166 00:06:36,125 --> 00:06:38,285 patients don't know where to go to find 167 00:06:38,285 --> 00:06:40,539 the patients that preserve motion. 168 00:06:41,160 --> 00:06:41,660 So 169 00:06:42,039 --> 00:06:43,099 we created, 170 00:06:44,120 --> 00:06:46,839 the top doctors in artificial disc replacement or 171 00:06:46,839 --> 00:06:48,060 arthroplasty directory. 172 00:06:48,519 --> 00:06:49,019 It's, 173 00:06:49,720 --> 00:06:52,300 basically, adrspine.com. 174 00:06:52,839 --> 00:06:55,115 And that lists doctors that 175 00:06:55,735 --> 00:06:58,555 I have personally reviewed that have 176 00:06:59,495 --> 00:06:59,995 experience 177 00:07:00,535 --> 00:07:03,274 doing artificial discs with good outcomes. 178 00:07:03,814 --> 00:07:05,975 And so we provide that directory so the 179 00:07:05,975 --> 00:07:08,300 patients can go there and kinda look for 180 00:07:08,300 --> 00:07:10,960 patients that are doctors that are near their 181 00:07:11,180 --> 00:07:13,100 areas. So they don't have to travel so 182 00:07:13,100 --> 00:07:14,460 far. I mean, I love it when they 183 00:07:14,460 --> 00:07:15,900 all fly out here to see me. That's 184 00:07:15,900 --> 00:07:18,379 great. But but if they, you know, if 185 00:07:18,379 --> 00:07:20,800 they wanna stay, you know, closer to home, 186 00:07:20,860 --> 00:07:22,160 if it's a more simple 187 00:07:23,345 --> 00:07:24,324 type of procedure, 188 00:07:25,264 --> 00:07:25,764 then 189 00:07:26,144 --> 00:07:28,165 they can find doctors near them. 190 00:07:29,105 --> 00:07:30,884 And how much has this, ADR 191 00:07:31,345 --> 00:07:33,685 list grown in recent years? 192 00:07:34,705 --> 00:07:36,785 We launched it last year, so it's pretty 193 00:07:36,785 --> 00:07:37,285 new. 194 00:07:37,709 --> 00:07:39,870 We have about 10 doctors on it now, 195 00:07:39,870 --> 00:07:41,889 I believe. We're adding more 196 00:07:42,750 --> 00:07:44,910 as time goes on. I have one of 197 00:07:44,910 --> 00:07:47,149 my spine fellows now I'll be adding on 198 00:07:47,149 --> 00:07:49,250 the East Coast. He's been sending me his 199 00:07:49,310 --> 00:07:51,254 post op films because he wants to get 200 00:07:51,254 --> 00:07:53,175 on the site, and I'm kinda picky about 201 00:07:53,175 --> 00:07:54,775 who can be on there because I wanna 202 00:07:54,775 --> 00:07:56,074 know that they have experience. 203 00:07:56,775 --> 00:07:58,295 And so I told him, I said, you 204 00:07:58,295 --> 00:07:59,435 made the cut. So 205 00:07:59,814 --> 00:08:01,895 his name's Cameron Murphy. I'll be adding him 206 00:08:01,895 --> 00:08:02,634 on soon. 207 00:08:03,009 --> 00:08:03,449 And, 208 00:08:03,889 --> 00:08:05,569 so there'll be more, but I'm I'm just 209 00:08:05,569 --> 00:08:06,550 wanna be careful 210 00:08:06,930 --> 00:08:09,330 and add add doctors that I know that 211 00:08:09,330 --> 00:08:11,649 are and, we run into some issues where 212 00:08:11,649 --> 00:08:13,569 some doctors are in big groups, and then 213 00:08:13,569 --> 00:08:14,310 the group 214 00:08:15,495 --> 00:08:18,055 corporate structure doesn't want them to be listed 215 00:08:18,055 --> 00:08:20,134 on another site and things like that. But 216 00:08:20,134 --> 00:08:22,055 we're trying to work around that. So it's 217 00:08:22,055 --> 00:08:25,095 pretty new, but it it's out there. In 218 00:08:25,095 --> 00:08:27,495 in that website, also, we show all of 219 00:08:27,495 --> 00:08:29,735 the different discs that are FDA approved, how 220 00:08:29,735 --> 00:08:32,470 they work. So patients have a resource 221 00:08:32,929 --> 00:08:35,490 to learn more about, gee, what is the 222 00:08:35,490 --> 00:08:37,889 disc this doctor recommends, and what is what's 223 00:08:37,889 --> 00:08:39,730 different about the other discs, right? You have 224 00:08:39,730 --> 00:08:41,269 nine discs FDA approved 225 00:08:41,649 --> 00:08:43,809 in The United States. Well, they all work 226 00:08:43,809 --> 00:08:44,790 a little differently. 227 00:08:45,495 --> 00:08:47,835 And it's not a one size fits all. 228 00:08:48,215 --> 00:08:49,995 And so I don't like it when 229 00:08:50,615 --> 00:08:53,014 I talk to artificial disc replacement surgeons, like, 230 00:08:53,014 --> 00:08:55,335 well, I always use this one disc. Well, 231 00:08:55,335 --> 00:08:57,095 that may or may not be a good 232 00:08:57,095 --> 00:08:57,595 thing 233 00:08:58,500 --> 00:09:01,240 because each patient has different anatomy 234 00:09:01,620 --> 00:09:02,840 and different angles, 235 00:09:03,379 --> 00:09:06,419 and their motion is different. And certain implants 236 00:09:06,419 --> 00:09:08,600 will work better in them than in others. 237 00:09:09,299 --> 00:09:12,065 And that's sort of taking it up another 238 00:09:12,065 --> 00:09:12,565 notch 239 00:09:12,944 --> 00:09:14,304 or or a higher level. So I'm trying 240 00:09:14,304 --> 00:09:15,904 to find doctors who are a little more 241 00:09:15,904 --> 00:09:18,544 savvy, who can provide that expert care that 242 00:09:18,544 --> 00:09:19,605 the patients need. 243 00:09:20,384 --> 00:09:21,824 Got it. And I want to circle back 244 00:09:21,824 --> 00:09:23,924 on what you were saying earlier about the 245 00:09:24,519 --> 00:09:25,820 ViscoSoft type of 246 00:09:26,279 --> 00:09:27,500 artificial discs. 247 00:09:27,960 --> 00:09:28,779 Do you look 248 00:09:29,080 --> 00:09:32,679 what do you think these devices need so 249 00:09:32,679 --> 00:09:35,580 they don't have this wear and tear issue? 250 00:09:36,695 --> 00:09:39,335 Well, the the one so each of the 251 00:09:39,335 --> 00:09:41,195 the the ones that are out there, 252 00:09:41,575 --> 00:09:43,915 that are OUS or outside The US 253 00:09:44,535 --> 00:09:46,215 and the one that was here in The 254 00:09:46,215 --> 00:09:46,715 US, 255 00:09:47,575 --> 00:09:48,794 they all have polycarbonate 256 00:09:49,254 --> 00:09:52,540 urethane cores, which is the softer's more springier 257 00:09:52,600 --> 00:09:53,100 core. 258 00:09:53,960 --> 00:09:56,700 That core seems to be relatively resilient, 259 00:09:57,160 --> 00:09:58,379 but it's it's 260 00:09:59,879 --> 00:10:01,820 the method that which it's encapsulated 261 00:10:02,360 --> 00:10:03,179 around it 262 00:10:03,639 --> 00:10:04,379 is variable. 263 00:10:05,000 --> 00:10:05,500 And 264 00:10:07,335 --> 00:10:10,615 the mechanical structure of the fibers that are 265 00:10:10,615 --> 00:10:12,794 woven around that core 266 00:10:13,335 --> 00:10:14,235 are different. 267 00:10:14,855 --> 00:10:15,995 Some of them have 268 00:10:16,455 --> 00:10:18,715 a different type of of elastic 269 00:10:19,169 --> 00:10:21,990 polymer. Some of them have a weave 270 00:10:22,529 --> 00:10:25,250 of a ultra high molecular weight polyethylene, like 271 00:10:25,250 --> 00:10:27,330 fishing line, like a weave around it. And 272 00:10:27,330 --> 00:10:28,309 those fibers 273 00:10:29,089 --> 00:10:30,710 may possibly be tearing, 274 00:10:31,570 --> 00:10:33,029 because they do not resist, 275 00:10:34,214 --> 00:10:36,294 not to get too much into biomechanics here, 276 00:10:36,294 --> 00:10:38,075 but what's called a shear. 277 00:10:39,654 --> 00:10:41,274 Ultra high molecular weight polyethylene 278 00:10:42,054 --> 00:10:43,355 has great tensile 279 00:10:43,735 --> 00:10:45,615 strength, like a fishing line. Like, it'll pull 280 00:10:45,615 --> 00:10:47,190 a fish out of the water. But if 281 00:10:47,190 --> 00:10:49,269 you wanna push it on a sheer like 282 00:10:49,269 --> 00:10:51,769 a crossways, it'll just cut right in half. 283 00:10:52,070 --> 00:10:54,009 So we think that there may be shearing 284 00:10:54,470 --> 00:10:55,690 causing some failures, 285 00:10:56,070 --> 00:10:57,769 and then the core can expulse, 286 00:10:58,710 --> 00:11:00,309 out of the implant, and then you're you're 287 00:11:00,309 --> 00:11:02,230 just sitting the metal part sits on the 288 00:11:02,230 --> 00:11:02,894 metal part. 289 00:11:03,375 --> 00:11:05,475 We've seen a a lot of wear debris 290 00:11:05,695 --> 00:11:08,415 occurring because they it's softer, so it there's 291 00:11:08,415 --> 00:11:10,035 debris. There's a microparticulate 292 00:11:10,735 --> 00:11:11,715 debris that occurs 293 00:11:12,335 --> 00:11:13,315 that also 294 00:11:13,695 --> 00:11:16,230 leaks out around the implant and can affect 295 00:11:16,290 --> 00:11:18,629 the bone, then the bone gets some resorption 296 00:11:19,410 --> 00:11:21,190 and can cause holes in it. 297 00:11:21,570 --> 00:11:22,070 So, 298 00:11:23,330 --> 00:11:24,149 right now, 299 00:11:24,610 --> 00:11:27,649 at this time in place, I am in 300 00:11:27,649 --> 00:11:29,670 a little bit more in favor of 301 00:11:30,444 --> 00:11:33,164 the hardcore discs. I know that they're gonna 302 00:11:33,164 --> 00:11:33,664 last. 303 00:11:34,125 --> 00:11:36,044 And and, you know, I have four of 304 00:11:36,044 --> 00:11:37,904 them implanted in me too. So 305 00:11:38,284 --> 00:11:41,164 and they've been in since 02/2008. So, and 306 00:11:41,164 --> 00:11:43,164 they look great on X-ray as of last 307 00:11:43,164 --> 00:11:45,664 year. So I know that they last, 308 00:11:47,089 --> 00:11:48,230 and I know that 309 00:11:48,610 --> 00:11:50,850 they function well. And I don't really have 310 00:11:50,850 --> 00:11:53,190 any back or neck pain anymore. So, 311 00:11:54,769 --> 00:11:57,509 I sort of push more towards that. 312 00:11:59,009 --> 00:12:00,629 I do love some of the biomechanical 313 00:12:02,205 --> 00:12:03,665 features of the viscoelastic 314 00:12:04,045 --> 00:12:05,665 core. I mean, it really replicates 315 00:12:06,125 --> 00:12:09,504 exactly the physiologic motion of a human disc. 316 00:12:09,965 --> 00:12:11,825 However, we have to work harder 317 00:12:12,285 --> 00:12:15,105 on figuring out how to make that device 318 00:12:15,644 --> 00:12:16,144 more 319 00:12:17,330 --> 00:12:18,470 viable in longevity. 320 00:12:18,929 --> 00:12:21,350 It needs to last and not break down. 321 00:12:21,490 --> 00:12:22,790 Because patients really 322 00:12:23,490 --> 00:12:25,350 you know, nobody wants to have a revision 323 00:12:25,410 --> 00:12:26,230 or an exploitation 324 00:12:26,929 --> 00:12:27,750 of their device. 325 00:12:29,090 --> 00:12:31,169 I wanna pivot a little bit here. Can 326 00:12:31,169 --> 00:12:33,545 you talk about some of the top challenges 327 00:12:33,545 --> 00:12:35,625 that you're facing in your practice right now 328 00:12:35,625 --> 00:12:37,404 and how you're getting ahead of them? 329 00:12:38,024 --> 00:12:40,045 Well, the main the main challenge, 330 00:12:42,345 --> 00:12:43,325 is insurance. 331 00:12:43,785 --> 00:12:44,605 Right? Because 332 00:12:45,144 --> 00:12:47,004 what a lot of people don't understand, 333 00:12:48,449 --> 00:12:50,370 the patients are like, well, why isn't my 334 00:12:50,370 --> 00:12:53,730 insurance approving a two level lumbar artificial disc 335 00:12:53,730 --> 00:12:55,509 when that's been FDA approved 336 00:12:56,449 --> 00:12:57,509 for several years? 337 00:12:58,049 --> 00:12:58,549 And 338 00:13:00,129 --> 00:13:01,269 insurance companies 339 00:13:03,345 --> 00:13:05,264 like to look at the studies that have 340 00:13:05,264 --> 00:13:05,924 been done. 341 00:13:06,865 --> 00:13:07,365 And 342 00:13:08,384 --> 00:13:10,705 the original studies in the low back, for 343 00:13:10,705 --> 00:13:13,985 example, the lumbar disc replacement, were we did 344 00:13:13,985 --> 00:13:15,445 both one and two level, 345 00:13:15,985 --> 00:13:17,524 but we got the one level 346 00:13:18,289 --> 00:13:20,870 approval from the FDA in 02/2005. 347 00:13:21,329 --> 00:13:23,329 That's a long time ago. That's twenty years 348 00:13:23,329 --> 00:13:23,829 ago. 349 00:13:24,370 --> 00:13:26,449 And these insurance companies, there's still a few 350 00:13:26,449 --> 00:13:28,929 insurance companies that still won't approve them at 351 00:13:28,929 --> 00:13:30,709 all. They still call them experimental, 352 00:13:31,569 --> 00:13:32,230 which is 353 00:13:32,605 --> 00:13:33,424 it's criminal. 354 00:13:34,044 --> 00:13:35,264 Whereas they'll approve 355 00:13:36,845 --> 00:13:39,404 fusions of five discs, all five of your 356 00:13:39,404 --> 00:13:41,485 discs in your low back. They'll insurance will 357 00:13:41,485 --> 00:13:43,184 approve that in a in a second, 358 00:13:43,644 --> 00:13:45,884 and they won't approve of one artificial disc. 359 00:13:45,884 --> 00:13:49,110 And the data is unequivocally clear showing superiority, 360 00:13:49,970 --> 00:13:51,429 we have two level approval. 361 00:13:51,809 --> 00:13:54,610 I'd say most insurances won't even approve that. 362 00:13:54,610 --> 00:13:56,690 And if I wanna put three artificial discs 363 00:13:56,690 --> 00:13:58,549 in, none of them will approve it, 364 00:13:58,850 --> 00:14:01,725 which is insane because the FDA says, and 365 00:14:01,725 --> 00:14:03,504 when you look at their website carefully, 366 00:14:04,445 --> 00:14:06,365 when they approve a device, they're saying that, 367 00:14:06,365 --> 00:14:08,764 say, the device is safe and effective. And 368 00:14:08,764 --> 00:14:10,365 it says right there, it says if the 369 00:14:10,365 --> 00:14:10,865 physician 370 00:14:12,044 --> 00:14:13,825 chooses to use this device 371 00:14:14,570 --> 00:14:16,730 in what's termed an off label manner, and 372 00:14:16,730 --> 00:14:18,330 I'll explain that in a minute, it's up 373 00:14:18,330 --> 00:14:19,709 to the doctor and the patient 374 00:14:20,330 --> 00:14:22,429 because that's that's our decision. 375 00:14:22,970 --> 00:14:24,889 What what off label and on label mean 376 00:14:24,889 --> 00:14:26,730 is on label is when we did the 377 00:14:26,730 --> 00:14:29,549 clinical trial, we did one or two level. 378 00:14:30,174 --> 00:14:31,855 That so if I said you need a 379 00:14:31,855 --> 00:14:34,575 one or two level disc replacement, that's on 380 00:14:34,575 --> 00:14:37,934 label because that's how the FDA clinical trial 381 00:14:37,934 --> 00:14:39,154 approval was done. 382 00:14:40,174 --> 00:14:40,674 Then 383 00:14:41,054 --> 00:14:42,654 if I say, well, I wanna do a 384 00:14:42,654 --> 00:14:45,690 three level, that's off label, but that's not 385 00:14:45,690 --> 00:14:46,190 illegal. 386 00:14:46,570 --> 00:14:48,329 It's not it's fine. It's 387 00:14:49,289 --> 00:14:50,509 and, honestly, 388 00:14:51,769 --> 00:14:54,329 lumbar fine spinal fusions that are done all 389 00:14:54,329 --> 00:14:56,730 the time are all off label. The only 390 00:14:56,730 --> 00:14:59,070 on label indication for a fusion 391 00:15:00,105 --> 00:15:01,725 is a grade two 392 00:15:02,745 --> 00:15:03,884 lytic spondylolisthesis 393 00:15:04,504 --> 00:15:06,985 in it, which is a huge subluxation or 394 00:15:06,985 --> 00:15:09,625 slippage of your vertebrae. That's the only on 395 00:15:09,625 --> 00:15:13,039 label FDA approval. And this so insurance companies 396 00:15:13,039 --> 00:15:15,919 seem to ignore that, approve those types of 397 00:15:15,919 --> 00:15:16,419 fusions, 398 00:15:17,039 --> 00:15:19,840 which are incredibly debilitating, in my opinion, to 399 00:15:19,840 --> 00:15:21,220 the patients. They they 400 00:15:21,519 --> 00:15:23,460 they it helps their pain, 401 00:15:24,125 --> 00:15:26,225 and their pains are better, but they're incredibly 402 00:15:26,284 --> 00:15:27,504 limited on their mobility. 403 00:15:27,884 --> 00:15:29,424 And patients don't want 404 00:15:29,804 --> 00:15:30,865 to lose motion. 405 00:15:31,485 --> 00:15:32,845 You know, back in the day and I 406 00:15:32,845 --> 00:15:34,464 do a do a lecture on this. 407 00:15:35,004 --> 00:15:36,605 Back in the nineteen fifties, if you had 408 00:15:36,605 --> 00:15:37,825 an arthritic hip, 409 00:15:38,365 --> 00:15:39,504 they fused it. 410 00:15:40,110 --> 00:15:42,269 They didn't have a total hip till 1958 411 00:15:42,269 --> 00:15:44,769 when Robert Charnley invents the total hip replacement. 412 00:15:45,389 --> 00:15:46,830 And I put up slides of all the 413 00:15:46,830 --> 00:15:49,629 famous hip replacement surgeons at the time who 414 00:15:49,629 --> 00:15:51,950 all said that's a fad. That device is 415 00:15:51,950 --> 00:15:54,434 not gonna work. That hip replacement thing is 416 00:15:54,434 --> 00:15:56,274 kind of a joke. My patients are very 417 00:15:56,274 --> 00:15:58,215 happy with the hip fusion. 418 00:15:58,754 --> 00:16:00,674 And if you see some really elderly people 419 00:16:00,674 --> 00:16:02,514 walking around with a straight leg, you'll know 420 00:16:02,514 --> 00:16:04,274 why. They they used to fuse your knee 421 00:16:04,274 --> 00:16:05,095 and your hip. 422 00:16:05,634 --> 00:16:06,134 And 423 00:16:06,590 --> 00:16:08,429 today, if your doctor said he's gonna fuse 424 00:16:08,429 --> 00:16:10,110 your hip or knee, you would be running 425 00:16:10,110 --> 00:16:12,129 out the door. But people 426 00:16:12,590 --> 00:16:14,929 get their spines fused all day 427 00:16:15,629 --> 00:16:17,629 when the option of motion is there. I 428 00:16:17,629 --> 00:16:19,790 mean, why wouldn't you get an artificial disc 429 00:16:19,790 --> 00:16:20,269 if you're 430 00:16:20,975 --> 00:16:21,875 unless you're 431 00:16:22,175 --> 00:16:24,415 really not a good candidate, which in my 432 00:16:24,415 --> 00:16:26,195 opinion is that that 433 00:16:27,215 --> 00:16:29,634 is becoming a smaller window. But 434 00:16:30,175 --> 00:16:32,735 who would want to not preserve mobility and 435 00:16:32,735 --> 00:16:34,355 have their pain relieved both 436 00:16:35,070 --> 00:16:37,549 and and maintain the motion that they wanna 437 00:16:37,549 --> 00:16:39,470 have so they can have an active functional 438 00:16:39,470 --> 00:16:40,610 life as they age. 439 00:16:41,389 --> 00:16:43,730 So, yeah, that's that's basically 440 00:16:44,670 --> 00:16:46,210 what our challenges are. 441 00:16:47,004 --> 00:16:48,924 Got it. And then my last question for 442 00:16:48,924 --> 00:16:51,564 you, doctor Landman, how are you thinking about 443 00:16:51,564 --> 00:16:53,024 growth at your practice? 444 00:16:54,125 --> 00:16:56,625 The thing I'm really working on now 445 00:16:57,245 --> 00:16:59,485 and, again, this is off label, but still, 446 00:16:59,485 --> 00:17:00,865 it's not it's not 447 00:17:01,379 --> 00:17:03,779 illegal. It's just fine. But I have a 448 00:17:03,779 --> 00:17:06,200 lot of patients coming in to see me 449 00:17:06,900 --> 00:17:07,720 who have 450 00:17:08,660 --> 00:17:09,320 had fusions, 451 00:17:10,259 --> 00:17:12,039 and they're in terrible pain. 452 00:17:13,140 --> 00:17:13,779 Some of them 453 00:17:14,815 --> 00:17:16,815 part of the fusion didn't heal. Some of 454 00:17:16,815 --> 00:17:18,914 them, all the fusion heal, but the way 455 00:17:19,215 --> 00:17:20,755 they they fused him 456 00:17:21,375 --> 00:17:23,535 or her, their their neck is out of 457 00:17:23,535 --> 00:17:25,875 alignment. Their low back is out of alignment, 458 00:17:26,575 --> 00:17:28,515 and they need to be rebalanced 459 00:17:28,815 --> 00:17:31,390 in alignment. Because ours, when you stand, it's 460 00:17:31,390 --> 00:17:33,849 a it's it's a balance. Right? Your head, 461 00:17:34,070 --> 00:17:35,910 your ears should be over your shoulders, over 462 00:17:35,910 --> 00:17:36,570 your hips. 463 00:17:37,109 --> 00:17:39,269 But sometimes, the fusions are done, and they're 464 00:17:39,269 --> 00:17:42,230 parking your head position too far forward or 465 00:17:42,230 --> 00:17:43,369 your back 466 00:17:43,855 --> 00:17:46,595 far forward. You see people walking kinda bent, 467 00:17:46,734 --> 00:17:47,714 and they're confused. 468 00:17:48,255 --> 00:17:50,174 And they have pain all the time because 469 00:17:50,174 --> 00:17:51,714 the muscles of your spine 470 00:17:52,654 --> 00:17:55,474 are always trying to rebalance you. It's subconscious. 471 00:17:56,255 --> 00:17:59,170 Your your muscles start they're under tension. That's 472 00:17:59,170 --> 00:18:01,170 why people have these muscle spasms, and they're 473 00:18:01,170 --> 00:18:03,670 in chronic pain. So what we've been doing 474 00:18:04,130 --> 00:18:06,850 and I've been working on very hard is 475 00:18:06,850 --> 00:18:10,210 restorative motion surgery, where I go in, I 476 00:18:10,210 --> 00:18:10,710 remove 477 00:18:11,250 --> 00:18:14,325 the fusion, and place an artificial disc and 478 00:18:14,325 --> 00:18:14,825 restore 479 00:18:15,525 --> 00:18:16,025 motion. 480 00:18:16,644 --> 00:18:18,244 And I'll be talking about that at the 481 00:18:18,244 --> 00:18:20,644 ISAS meeting here in Miami coming up next 482 00:18:20,644 --> 00:18:22,825 month and presenting my data 483 00:18:23,125 --> 00:18:23,845 of over, 484 00:18:24,724 --> 00:18:26,184 50 plus patients 485 00:18:26,970 --> 00:18:29,690 and the outcomes. And it's quite encouraging. The 486 00:18:29,690 --> 00:18:32,730 reduction in pain scores is dramatic. The the 487 00:18:32,730 --> 00:18:33,390 the motion, 488 00:18:34,089 --> 00:18:36,329 restoration, and I measured all of this, and 489 00:18:36,329 --> 00:18:39,049 I'll be talking about that. But restorative motion 490 00:18:39,049 --> 00:18:39,549 surgery, 491 00:18:40,329 --> 00:18:40,829 remove 492 00:18:41,130 --> 00:18:42,029 removing fusions, 493 00:18:43,024 --> 00:18:44,565 removing failed fusions, 494 00:18:45,105 --> 00:18:48,384 and converting those to artificial discs. Not everybody's 495 00:18:48,384 --> 00:18:50,544 a candidate, but a lot of people are. 496 00:18:50,544 --> 00:18:52,704 And when I do that, the results are 497 00:18:52,704 --> 00:18:55,825 just fantastic because people have full restorative motion 498 00:18:55,825 --> 00:18:56,964 of their spine again. 499 00:18:57,349 --> 00:18:59,769 So it's exciting. I'm very excited about that. 500 00:19:00,070 --> 00:19:01,529 Really encouraging to hear. 501 00:19:01,830 --> 00:19:03,990 And, doctor Lamond, thank you so much for 502 00:19:03,990 --> 00:19:06,150 joining us today. It's been a pleasure speaking 503 00:19:06,150 --> 00:19:08,309 with you, and I look forward to connecting 504 00:19:08,309 --> 00:19:10,390 with you again down the line. Thank you, 505 00:19:10,390 --> 00:19:12,390 Carly. I appreciate it. It was great to 506 00:19:12,390 --> 00:19:13,130 talk to you.